Preview

How to Identify Data in Nursing Field

Good Essays
Open Document
Open Document
587 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
How to Identify Data in Nursing Field
1. The nursing process is the core for the nursing care plan and enables one to think like a nurse. The nursing process is important as it is a systematic problem solving approach which involves the partnership with both the patient and their family. It serves as an important tool to improve practice, quality care and promote good health. The nursing process has four phases include assessment, diagnosis ,planning, implementing, evaluation.
2. One of the components of assessment would be the Chief complaint. the chief complaint is a brief statement of whatever is troubling the patient and the duration of time the problem has existed. The chief complaint is the signs and symptoms causing the patient to seek medical attention. Generally, it is the answer to the question, "What brought you into the hospital (or clinic) today?" If a well person is seeking a routine physical, there is no actual chief complaint
Another component of assessment is the past medical history. This provides background for understanding the patient as a whole and his present illness. It includes childhood illnesses, immunizations, allergies, hospitalizations and serious illnesses, accidents and injuries, medications, and habits.
Family health history. This enhances your understanding of the environment in which the patient lives. Obtaining this information identifies genetic problems, communicable diseases, environmental problems, and interpersonal relationships. Specific inquiry should be made regarding the general state of health of parents, grandparents, siblings, spouse, and children. Record if the patient is adopted and has no access to his biological family's history.
3.In the health history,during this assessment you must interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient's individual needs. The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors,

You May Also Find These Documents Helpful

  • Satisfactory Essays

    When doing your assessment of a patient, regardless if it is an admission, surgical, emergency visit or just routine visit, you need a method, pattern to ensure completion. I am going to focus on the admission assessment. When a patient comes to the hospital, the initial assessment will plan the care. “The physical examination requires you to develop technical skills and a knowledge base.” (Jarvis, 2012)…

    • 366 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”…

    • 1111 Words
    • 6 Pages
    Powerful Essays
  • Good Essays

    Hcr 220 Week 3 Assignment

    • 899 Words
    • 4 Pages

    During the new patient intake process, the patient comes to the office for the visit. Upon arrival the patient is given multiple forms to fill out. Medical History is important in understanding about a patient. It is important that physicians have access to a patient’s most recent medical history. A patient’s medical history may include personal medical history, family medical history, social history, or any medications or therapies currently used. Social history contains personal lifestyles choices, such as smoking, exercise or alcohol use. Patients are also asked to complete patient information forms. Patient…

    • 899 Words
    • 4 Pages
    Good Essays
  • Good Essays

    . In the December 2007 issue of Nursing Standards, Hilary Lloyd and Stephen Craig explain the process and importance of taking a full and comprehensive patient health history in the article, “A guide to taking a patient’s history”. General principles, tools and strategies are outlined in this article to assist the nurse when performing a health history assessment for a patient in any setting.…

    • 731 Words
    • 3 Pages
    Good Essays
  • Good Essays

    The nursing process of assessment; planning: intervention and evaluation assists health care professionals with problem solving, and advocates the personal holistic provision of care but at the patient from a holistic view, in order to provide effective care giving (Slevin 2001) then plan and set goals according to the information gathered. The…

    • 1486 Words
    • 6 Pages
    Good Essays
  • Better Essays

    This article focused on the importance of taking a comprehensive health history and pointed out that this task is increasingly being undertaken by nurses. The article proposed that taking a logical, systematic approach when taking a patient’s health history allows for the most comprehensive collection of information. The article identified the Calgary Cambridge framework as a model for use during the interview process and stated that it is helpful for both new and seasoned nurses. It provides five suggested stages to implement during the interview process which include; explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation (Lloyd & Craig, 2007, p.44)…

    • 1230 Words
    • 5 Pages
    Better Essays
  • Good Essays

    Patient does not have a present illness. He is only seeking care for the purpose of providing a health history for the interviewer’s assignment.…

    • 3953 Words
    • 16 Pages
    Good Essays
  • Better Essays

    After learning what the patient has arrived for, the nurse must start gathering data that relates to the patient’s chief complaint. For example, if the patient presents with shortness of breath, it is important to gather data such as: oxygen saturation, respiratory rate and effort, lung auscultation, presence of cough, and observing patient color. In…

    • 2710 Words
    • 8 Pages
    Better Essays
  • Better Essays

    Self-esteem and Care Plan

    • 1482 Words
    • 6 Pages

    * By asking the individual at their initial assessment, a full history should be taken as part of their care plan…

    • 1482 Words
    • 6 Pages
    Better Essays
  • Satisfactory Essays

    Bloom’s Taxonomy

    • 621 Words
    • 3 Pages

    Something like, which sign or symptom is the nurse likely to assess if the client’s…

    • 621 Words
    • 3 Pages
    Satisfactory Essays
  • Best Essays

    Care Study Y2

    • 4736 Words
    • 19 Pages

    The nursing process framework plays an important part in patient assessment and care. This is the process of assessing, planning, implementing and evaluating (APIE) and was introduced into nursing by Yura and Walsh (1967). They called it the nursing process…

    • 4736 Words
    • 19 Pages
    Best Essays
  • Good Essays

    assessment with all systems are included as well a full health history . In the review of systems health care professionals obtain answers to a series of questions to identify signs and symptoms which the patient may be experiencing or has experienced. This kind of Information is used to identify the patient problem, assist in the arrival at a diagnosis, identify differential diagnoses, and determine the testing necessary to attain a definitive diagnosis. In a problem focused assessment clinician may give more importance to the ,Chief Complaint (CC)…

    • 210 Words
    • 1 Page
    Good Essays
  • Good Essays

    Health Assessment

    • 825 Words
    • 4 Pages

    According to our text book, client ability to cope with illness and stress has a great impact on patients’ psychosocial health (Amico & Barbarito, 2012, pg.87).…

    • 825 Words
    • 4 Pages
    Good Essays
  • Better Essays

    Journal Article Review

    • 1671 Words
    • 7 Pages

    ‘A guide to taking a patient’s history’ is an article published in the Nursing Standard Journal, volume 22, issue 13, dated December 5, 2007, written by Hillary Lloyd and Stephen Craig. In this article, Lloyd and Craig describe the most effective and professional way to take a history from a patient in a variety of settings and the strategic reasons why doing so will achieve the best results.…

    • 1671 Words
    • 7 Pages
    Better Essays
  • Good Essays

    Rn vs. Lpn

    • 770 Words
    • 4 Pages

    When a patient is first admitted for care, the initial assessment is performed by an RN in most cases. This assessment includes a thorough history, physcial exam and the collection…

    • 770 Words
    • 4 Pages
    Good Essays